Available Parenteral Nutrition

An overview of the macronutrient components of PN and the pre-mixed options commonly available for adult and pediatric PN.

Parenteral nutrition (PN) regimens contain different components, including water, macronutrients (carbohydrates, lipids, amino acids), electrolytes, micronutrients (trace elements, vitamins) and other additives (e.g. glutamine, insulin, heparin). They can be administered either using separate containers, or from an 'all-in-one' bag system prepared in the hospital pharmacy or by industry.1


To learn more about the macronutrient components of PN, please select the link below:

All-in-one parenteral nutrition solutions

All-in-one PN solutions are commonly administered from a closed-bag system.2


There are two sources of all-in-one mixtures:

  • Locally-prepared solutions, prepared manually or with an automated compounding device2
  • Commercially-manufactured multi-chamber bags (MCBs). There are currently two types of MCBs:
    • Double-chamber bags: one compartment contains an amino acid solution and the other contains glucose (with or without electrolytes). The lipid component, if used, must be administered from a separate bag2
    • Triple-chamber bags: all the macronutrients (with or without electrolytes) are contained in three separate compartments2
    • If vitamins and trace elements are required, they can be injected into the two- or three-chamber bags, or infused through a separate line.2

To learn more about PN options commonly available for adult and pediatric PN, please select from the links below:


PN pre-mixed options available for pediatric PN

For pediatric patients of all ages, international guidelines from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN) state that the main goal of nutritional therapy is to sustain growth.3 International guidelines from ESPGHAN/ESPEN, have been issued to aid clinicians in prescribing a balanced formulation of nutrients to meet nutritional needs based on the individual circumstances and the age and size of the infant or child3 and pediatric guidelines have also been developed by the American Society for Parenteral and Enteral Nutrition (ASPEN) and the American Association of Pediatrics (AAP) (see Parenteral Nutrition Guidelines).


Currently only a limited number of commercially pre-mixed solutions are available for PN in preterm and term infants that can be administered by a central line.4–8 Throughout Europe, standardized, pediatric PN admixtures are commercially available and licensed for use in this patient population.9–11 Otherwise, administration of PN from an all-in-one solution requires the use of locally-compounded mixtures or the use of commercial MCBs whose label indicates that they can be used in pediatric patients >2 years of age.

PN pre-mixed options available for adult PN

Several factors should be considered when choosing the most appropriate PN formulation to meet patients' diverse nutritional needs. These may include the following:

  • The amount of energy (glucose) and protein (nitrogen) required by the patient, as the demand for energy and protein varies with different diagnoses and also with the time course of the condition12
    • Different patients have different nitrogen needs according to levels of metabolic stress, e.g. patients with trauma, respiratory failure and sepsis may have a greater nitrogen demand than those patients undergoing elective surgery.12

Table 1 classifies patients into groups according to their nitrogen demand.12

Table 1. Nitrogen demand groups12*

Patients included* Nitrogen demand group
Mostly healthy subjects and some surgical patients Normal
Mostly patients admitted to hospital ward as a result of elective surgery, cancer, or malnutrition Moderate
Critical (intensive) care, patients with trauma, inflammatory bowel disease High
*Based upon general classification, individual needs will need to be defined

  • Additional nutritional requirements of the patient
    • Lipid emulsions provide a dense energy source. They also meet essential fatty acid nutritional requirements and membrane structural requirements.
  • The volume of the bag and the fluid requirements of the patient
    • Fluid intake is often a critical aspect in PN as volume overload can result in clinical complications such as peripheral edema, pulmonary edema, heart failure, requirement for diuretic medications, and poor wound healing.13–17
  • Osmolarity of the infused solution (for peripheral PN)
    • According to the ESPEN guidelines, low osmolarity of peripherally-administered infusions can help to prevent peripheral vein thrombophlebitis. These guidelines recommend that the osmolarity of the infused solution should not exceed 850mOsm/L when administered via a peripheral vein.18
  • The patient's needs for additional electrolytes, trace elements, and vitamins.
  • Critically-ill patients are susceptible to hyperglycemia, which may lead to infection, polyneuropathy and other serious complications.19

There are several two- or three-chamber pre-mixed solutions available for adult PN.20–30 These may be administered intravenously by the peripheral line or the central line depending on the osmolarity of the product.

Components of PN

Amino acids available for PN
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Commercially-available amino acid solutions for PN contain mixed amino acid products providing all nine essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine) in amounts varying between 38 and 57% of total amino acids and a varying composition of nonessential amino acids (e.g. alanine, arginine, glycine, proline, serine, and tyrosine).31 These amino acid formulations may also contain varying amounts of classically nonessential amino acids (e.g. cysteine) that may become conditionally essential under certain circumstances. These solutions are provided at different concentrations of amino acids with or without electrolytes.

Carbohydrates available for PN
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Dextrose provides a source of calories and is the most common carbohydrate used in PN solutions. Dextrose solutions are available in a range of concentrations and usually contributes most of the osmolality of the PN solution.3

Lipid emulsions available for PN
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There are several types of intravenous lipid emulsion available for adult and pediatric PN, and these differ in the type of oil used and the percentage of fat (10% or 20% emulsions).3


The most commonly used lipid source in PN formulations is soybean oil, a polyunsaturated fatty acid (PUFA). However, soybean oil emulsions have been reported to have several limitations, including:


  • Increased risk of enhanced lipid peroxidation32,33
  • Possible reduction in antioxidant defenses3
  • Possible suppressive effect on immune cells34
  • Possible hepatobiliary complications35
  • Possible effects on PUFA synthesis32
  • Increased phytosterol levels.36

Commercially-available parenteral lipid formulations include:1


  • Soybean oil-based formulations, often referred to as long-chain triglycerides (LCT)
  • 'Pharmaceutical' mixtures (usually 50:50) of soybean LCT and medium-chain triglycerides from coconut oil (MCT)
  • 'Pharmacological' mixtures, which are triglyceride mixtures with each glycerol molecule having a distribution of fatty acids with different chain lengths
  • Olive oil and soybean mixtures (80:20)
  • Mixtures of lipids including fish oil (e.g. mixtures of soybean, MCT, olive oil, and fish oil)
  • Fish oil alone, to be used as a supplement in combination with other emulsions.

References
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  1. Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr 2009;28:387–400.
  2. Mühlebach S, Franken C, Stanga Z, et al. Practical handling of AIO admixtures - Guidelines on Parenteral Nutrition, Chapter 10. Ger Med Sci 2009;7: Doc18.
  3. Koletzko B, Goulet O, Hunt J, et al. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41(Suppl. 2):S1–S87.
  4. Fresenius Kabi. Pediaven Baby 1, Summary of Product Characteristics.
  5. Fresenius Kabi. Pediaven Baby 2, Summary of Product Characteristics.
  6. Fresenius Kabi. Pediaven Baby 3, Summary of Product Characteristics.
  7. Fresenius Kabi. Pediaven Enfant G15, Summary of Product Characteristics.
  8. Fresenius Kabi. Pediaven Enfant G20, Summary of Product Characteristics.
  9. Fresenius Kabi. Pediaven Enfant G25, Summary of Product Characteristics.
  10. Fresenius Kabi. Babiven Start-Up and Maintenance, May 2010.
  11. Fresenius Kabi. NP100, Summary of Product Characteristics.
  12. Kreymann G, DeLegge MH, Luft G, Hise ME, Zaloga GP. The ratio of energy expenditure to nitrogen loss in diverse patient groups-a systematic review. Clin Nutr 2012;31:168–175.
  13. Mann DL. Heart failure and cor pulmonale. In: Fauci AS, et al, eds. Harrison's Principles of Internal Medicine, 17th ed. New York, NY: McGraw Hill; 2008:1443–1455.
  14. Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med 2005;353:2788–2796.
  15. Jessup M, Brozena S. Heart failure. N Engl J Med 2003;348:2007–2018.
  16. Jessup M, Abraham WT, Casey DE, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119:1977–2016.
  17. Bovill E, Banwell PE, Teot L, et al. International Advisory Panel on Topical Negative Pressure. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J 2008;5:511–529.
  18. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28:365–377.
  19. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359–1367.
  20. Baxter. Oliclinomel®. Summary of Product Characteristics.
  21. Baxter. Oliclinomel E®. Summary of Product Characteristics.
  22. Baxter. Olimel® PeriOLIMEL N4/OlimelPeri. Summary of Product Characteristics.
  23. Fresenius Kabi. Kabiven®/Kabiven® Peripheral. Summary of Product Characteristics.
  24. Fresenius Kabi. SmofKabiven®/SmofKabiven® Peripheral. Summary of Product Characteristics.
  25. Fresenius Kabi. StructoKabiven®/StructoKabiven® Peripheral. Summary of Product Characteristics.
  26. B. Braun. NuTRIflex® lipid/Nutriflex Lipid Peri/NuTRIflex® omega. Summary of Product Characteristics.
  27. Baxter. Clinimix® Summary of Product Characteristics.
  28. Baxter. Clinimix E® Summary of Product Characteristics.
  29. Fresenius Kabi. AminoMix® Summary of Product Characteristics.
  30. B. Braun. NuTRIflex® (Peri, basal, plus and special). Summary of Product Characteristics.
  31. Yarandi S, Zhao V, Hebbar G, Ziegler T. Amino acid composition in parenteral nutrition: what is the evidence? Curr Opin Clin Nutr Metab Care 2011;14:75–82.
  32. Göbel Y, Koletzko B, Böhles HJ, et al. Parenteral fat emulsions based on olive and soybean oils: a randomized clinical trial in preterm infants. J Pediatr Gastroenterol Nutr 2003;37:161–167.
  33. Goulet O, Antébi H, Wolf C, et al. A new intravenous fat emulsion containing soybean oil, medium-chain triglycerides, olive oil, and fish oil: a single-center, double-blind randomized study on efficacy and safety in pediatric patients receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr 2010;34:485–495.
  34. Gawecka A, Michalkiewicz J, Kornacka MK, et al. Immunologic properties differ in preterm infants fed olive oil vs soy-based lipid emulsions during parenteral nutrition. JPEN J Parenter Enteral Nutr 2008;32:448–453.
  35. Pálová S, Charvat J, Kvapil M. Comparison of soybean oil- and olive oil-based lipid emulsions on hepatobiliary function and serum triacylglycerols level during realimentation. J Int Med Res 2008;36:587–593.
  36. Saayman BD. The use of alternative lipid emulsions in paediatric and neonatal parenteral nutrition. S Afr J Clin Nutr 2011;24: S32–S34.